Provider Demographics
NPI:1306975263
Name:JOHNSON, PHILIP JAMES (MD)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:JAMES
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2418 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:FT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805
Mailing Address - Country:US
Mailing Address - Phone:260-422-4757
Mailing Address - Fax:260-422-8375
Practice Address - Street 1:2418 LAKE AVE
Practice Address - Street 2:
Practice Address - City:FT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805
Practice Address - Country:US
Practice Address - Phone:260-422-4757
Practice Address - Fax:260-422-8375
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01023461207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000083093OtherPIN BCBS
IN4062678OtherAETNA
IN4062678OtherAETNA
INC24160Medicare UPIN